Psychosocial Treatment of Schizophrenia

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4 Clinician s Guide to Evidence-Based Practice Series Treatment of Traumatized Adults and Children Allen Rubin and David W. Springer, Editors Substance Abuse Treatment for Youth and Adults David W. Springer and Allen Rubin, Editors Psychosocial Treatment of Schizophrenia Allen Rubin, David W. Springer, and Kathi Trawver, Editors

5 Clinician's Guide to Evidence-Based Practice Psychosocial Treatment of Schizophrenia Edited by ALLEN RUBIN, DAVID W. SPRINGER, and KATHI TRAWVER John Wiley & Sons, Inc.

6 This book is printed on acid-free paper. 1 Copyright c 2010 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) , fax (978) , or on the web at Requests to the Publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) , fax (201) Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought. Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration. For general information on our other products and services please contact our Customer Care Department within the United States at (800) , outside the United States at (317) or fax (317) Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley products, visit our website at Library of Congress Cataloging-in-Publication Data: Psychosocial treatment of schizophrenia/allen Rubin, David W. Springer, and Kathi Trawver, editors. p.; cm. (Clinician s guide to evidence-based practice series) Includes bibliographical references and indexes. ISBN (pbk.: alk. paper) 1. Schizophrenia Treatment. 2. Schizophrenia Treatment Social aspects. I. Rubin, Allen. II. Springer, David W. III. Trawver, Kathi. IV. Series: Clinician s guide to evidence-based practice series. [DNLM: 1. Schizophrenia therapy. 2. Evidence-Based Medicine. 3. Psychotherapy methods. 4. Schizophrenia drug therapy. 5. Social Environment. 6. Social Support. WM 203 P ] RC514.P dc Printed in the United States of America

7 This book is dedicated to the memory of my sister, Corrine Harris, and her husband, Morley Harris, who never stopped visiting my father after he was institutionalized for the rest of his life after getting a lobotomy for paranoid schizophrenia when I was a toddler. If only the medications and empirically supported psychosocial interventions described in this volume had been available to him back then! Allen Rubin

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9 Contents Series Introduction ix Preface xi Acknowledgments About the Editors xvii xix About the Contributors xxi Chapter 1 Overview and Clinical Implications of Schizophrenia 1 Allen Rubin and Kathi Trawver Chapter 2 A Guide to Implementation and Clinical Practice of Illness Management and Recovery for People with Schizophrenia 23 Piper S. Meyer, Susan Gingerich, and Kim T. Mueser Chapter 3 Psychoeducational Family Groups 89 Ellen Lukens and Helle Thorning Chapter 4 Cognitive-Behavioral Therapy for Schizophrenia 145 Dennis R. Combs Chapter 5 Assertive Community Treatment 187 Kathi Trawver Chapter 6 Critical Time Intervention 253 Daniel Herman, Sarah Conover, and Jeffrey Draine vii

10 viii Contents Chapter 7 Motivational Interviewing for Medication Adherence 283 Stanley G. McCracken and Jonathon E. Larson Appendix A Research Providing the Evidence Base for the Interventions in This Volume 341 Kathi Trawver and Allen Rubin Appendix B The Evidence-Based Practice Process 349 Allen Rubin Appendix C Atypical Antipsychotic Medications for Treating Schizophrenia 361 Kathi Trawver Author Index 375 Subject Index 385

11 Series Introduction One of the most daunting challenges to the evidence-based practice (EBP) movement is the fact that busy clinicians who learn of evidence-based interventions are often unable to implement them because they lack expertise in the intervention and lack the time and resources to obtain the needed expertise. Even if they want to read about the intervention as a way of gaining that expertise, they are likely to encounter materials that are either much too lengthy in light of their time constraints or much too focused on the research support for the intervention, with inadequate guidance to enable them to implement it with at least a minimally acceptable level of proficiency. This is the third in a series of edited volumes that attempt to alleviate that problem and thus make learning how to provide evidence-based interventions more feasible for such clinicians. Each volume will be a how-to guide for practitioners not a research focused review. Each will contain in-depth chapters detailing how to provide clinical interventions whose effectiveness is supported by the best scientific evidence. The chapters will differ from chapters in other reference volumes on empirically supported interventions in both length and focus. Rather than covering in depth the research support for each intervention and providing brief overviews of the practice aspects of the interventions, our chapters will be lengthier and will have more detailed practitioner-focused how-to guides for implementing the interventions. Instead of emphasizing the research support in the chapters, that support will be summarized in Appendix A. Each chapter will focus on helping practitioners learn how to begin providing the evidence-based interventions they are being urged by managed care companies (and others) to provide, but with which they may be inexperienced. Each chapter will be extensive and detailed enough to enable clinicians to begin providing the evidence-based intervention without being so lengthy and detailed that reading it would be too time-consuming and overwhelming. The chapters will also identify resources for gaining more advanced expertise in the interventions. ix

12 x Series Introduction We believe that this series will be unique in its focus on the needs of practitioners and in making empirically supported interventions more feasible for them to learn about and provide. We hope that you will agree and that you will find this volume and this series to be of value in guiding your practice and in maximizing your effectiveness as an evidence-based practitioner. Allen Rubin, Ph.D. David W. Springer, Ph.D.

13 Preface Schizophrenia is perhaps the most disabling of all mental disorders. It produces significant residual cognitive, functional, and social deficits. As such, its treatment is complex and multifaceted, requiring a multidisciplinary approach. Although psychotropic medications comprise a vital part of the treatment, they are not sufficient. A large proportion of persons with schizophrenia discontinue their medication against medical advice, whereas others continue to have symptoms despite medication management. Common reasons for medication noncompliance are the undesirable side effects often produced by the medications and the stigma associated with admitting to being mentally ill by virtue of adhering to the medication protocol. Thus, in addition to prescribing medications, the treatment plan must include components that motivate patients to adhere to the medication protocol and that monitor adherence and possible side effects. Furthermore, although medication adherence is necessary if treatment goals are to be achieved, it alone is insufficient for ensuring that problems related to social functioning, employment, and families will be adequately addressed. Treating schizophrenia does not just mean addressing hallucinations and delusions. It also means providing psychosocial interventions that address the social skills of the individual with schizophrenia, support their families, and give caregivers the skills they will need to cope with and support their sick loved one. In addition, it means providing a comprehensive array of community services that address housing and other needed resources, including the provision of case management efforts that aim to link the person with schizophrenia with needed services and resources. Despite the severity and challenging multifaceted and disabling nature of schizophrenia, grounds for optimism for its treatment grow as newer and better medications are discovered and as rigorous research emerges supporting the effectiveness of various psychosocial interventions. These interventions help individuals with this disorder take their medications and adapt better to the community and help their families cope with and support them. Nevertheless, too few individuals with schizophrenia are receiving the treatment they need, and fewer still receive treatment xi

14 xii Preface with sound evidence supporting its effectiveness. Drake, Bond, and Essock (2009) have reported that as many as 95% of people with schizophrenia receive either no treatment or treatment that is not evidence-based. This volume aims to ameliorate that problem by offering detailed how-to chapters to guide practitioners in providing both well-established and emerging empirically supported interventions that show promise for improving the lives of adults with schizophrenia people who need to have the most effective interventions offered to them in hopes of alleviating their suffering, enhancing their functioning, and supporting their recovery. After an introductory chapter that overviews schizophrenia and its symptoms and clinical implications, each subsequent chapter focuses on a specific psychosocial intervention approach. Each chapter is written in a practitioner-friendly manner, sprinkled with case examples throughout, to help readers learn how to provide interventions that are receiving the best empirical support without having to struggle with daunting research and statistical terminology. Each of those chapters has been written by practitioners who have had extensive experience in providing the referent intervention and who are experts in it. As already mentioned, a distinctive feature of the chapters is their length. Unlike other compendiums with shorter chapters on various interventions for schizophrenia chapters that emphasize the research supporting the interventions and offer briefer and sketchier guidance as to how to provide them the chapters in this volume provide extensive, detailed, step-by-step guidance to practitioners in how to implement each intervention approach. Thus, the chapters are a middle ground between the sketchier chapters in other compendiums and entire books devoted exclusively to one specific intervention approach. By taking this tack, we hope to enable practitioners who work with people affected by schizophrenia but who lack the time to read separate books on each intervention approach to make their practice more evidence-based and thus more effective. Organization As mentioned previously, the first chapter provides an overview of schizophrenia, including its etiology, diagnostic aspects, medications, and the importance of medication compliance. As suggested in that chapter, treatment of schizophrenia should be multifaceted, and those various facets are addressed in subsequent chapters. For example, in Chapter 2, Piper Meyer, Susan Gingerich, and Kim Mueser provide a step-by-step guide for implementing the illness management and recovery program that includes a wide range of components, such as psychoeducation, behavioral tailoring for medication, relapse prevention training, coping and social skills training, and building social support. In Chapter 3, Ellen Lukens and Helle Thorning describe how to implement an empirically supported family intervention. They note that the presence or emergence

15 Preface xiii of schizophrenia in a child, sibling, or parent can throw families into overpowering disarray. Family members commonly feel culpable for the illness, and that feeling too often gets reinforced by medical providers who find fault and pathology within the family. The psychoeducational multiple family group (PEMFG) intervention that Lukens and Thorning describe helps family members move from feeling blamed for their relative s illness to a point where they can be involved as collaborators in caring for and supporting their loved one. In Chapter 4, Dennis Combs turns our attention to an empirically supported treatment approach that targets underlying deficits in information processing that contribute to various symptoms of schizophrenia, especially delusions and hallucinations, and their attendant emotional distress. He offers an extensive, detailed guide for providing cognitive-behavioral therapy (CBT) for schizophrenia. Many adults with schizophrenia, however, have disorders that are so severe and disabling that they need a comprehensive community-based service delivery system to help them utilize treatment, avoid homelessness, function in the community, forestall decompensation, and prevent hospitalization or incarceration. In Chapter 5, Kathi Trawver describes such an approach: assertive community treatment (ACT), an empirically supported model that provides case management (an intervention that itself is empirically supported), but goes beyond it to provide an around-the-clock basis for the gamut of services needed by individuals who experience the most chronic and disabling effects of schizophrenia. In Chapter 6, Daniel Herman, Sarah Conover, and Jeffrey Draine describe another community-based approach, critical time intervention (CTI), which is an emerging empirically supported case management model designed to prevent homelessness among people with schizophrenia (or other severe disorders) during the transitional period after they are discharged from hospitals, prisons, shelters, and other institutions. As the authors explain, CTI shares some of the features of ACT but differs from it in that it is time limited to the period of transition from institution to community, does not provide direct ongoing assistance, and is more narrowly targeted to prevent homelessness. Finally, in Chapter 7, Stanley McCracken and Jonathon Larson offer detailed guidance in the use of motivational interviewing (MI) to foster medication adherence. Although the empirical support for the effectiveness of using MI for this purpose is still emerging, their chapter is important in light of the vital role of medication adherence in virtually all treatment plans for schizophrenia and the widespread problem of nonadherence (as mentioned earlier). This volume also contains three appendices. Appendix A reviews the research that provides the empirical support for the interventions covered in its seven chapters. Appendix B describes in detail the evidence-based practice process for readers who would like to learn more about finding and appraising research to guide their practice decisions. Appendix C provides a table displaying the antipsychotic medications prescribed for treating schizophrenia and their side effects.